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Sanitary Permit Application Safety&Buildings Division <br /> Asconsin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W Washington Ave. <br /> PO Box 7302 <br /> See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison,Wl 53707-7302 <br /> Department of Commerce it(Submcompleted form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] state owned.) <br /> Attach complete plans(to the county copy only)for the system,on pap not less than 8-1/2 x 11 inches in size. <br /> County. State Sanitary Permit Number ❑ k if r ision to previo application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: j44,31 FF3 L5 rAAA <br /> PropV Owner Name / Property Location/c, <br /> CA -/4/L)4 '1/A,S3,?TY/,N,R�E(or W <br /> Property Owner's Mailing Address f Lot Number Block Number <br /> 1 v{/ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building. check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: o` ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> ❑ State-Owned 1,!+r.5 <br /> Nearest$ga <br /> l7 <br /> It-�L.! IS�'arn-1�.1. <br /> Parcel Tax Num <br /> be s <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. §gReplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IY.Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> •Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> -T o v y� 9 5'� - / 7 <br /> ��� <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> S2 is 7Sp 7Sp S'ad rlc� ❑ ❑ ❑ ❑ <br /> yM <br /> ad — s-ov ❑ ❑ ❑ ❑ <br /> II.Re possibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no ps): MP/MPRS No. Business Phone Number <br /> "ale- P'V//0/ <br /> Plumber's Address(Street,City,State,Zip Code) ) <br /> S— Ys'7 Z <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui nt Signa o stamps) <br /> Approved El Owner Given Initial Adverse Surcharge Fee) <br /> Determination Z ! 1 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />